Professional Documents
Culture Documents
Subjective: Acute pain, related After 8 hours of Ask the patient to To be able to know After 8 hours of
to wound at the nursing rate the pain form 1 the degree of pain. nursing intervention
gluteal area. intervention the to 10 (1 is the the patient was able
lowest and 10 is the Establishes baseline
“ Kumikirot ang patient will able to to verbalize that the
highest.) for assessing
sugat ko” as verbalize the pain degree of pain is was
improvement/
verbalized by the is minimized/ changes lessen.
patient relieved within Determine pain
8hours. characteristics Avoids direct
through pt. pressure to area of
Description. injury which could
Place foot cradle on result in
bed and encourage vasoconstriction /
Objective: use of loose fitting increased pain.
slippers when up.
Facial grimace
Stay with client who To reduce the anxiety
is experiencing pain of the patient.
or appears anxious.
Maintain quiet,
comfortable For promote
environment; relaxation for the
restrict visitors as patient.
necessary.
Subjective: Impaired skin After 36 hrs of ● Obtain culture ● To identify After 36 hrs of nursing
intergrity related to nursing intervention of wound pathogens intervention the patient was
¨ Mahapdi ang bahagi physical the patient will be dranaige and theraphy able to verbalized feelings
ng sugat ko¨ as immobilization as able to participate in of choice of increased self esteem
verbalized by the manifested by wound prevention measures ● soat foot in ● Local and ability to manage
patient. in the gluteal area. and tretment room germicidal situation.
program and temperature effective for
verbalized feelings of sterile water surface
Objective: increased self esteem with betadine wounds.
and ability to manage solution TID keeps clean /
● Disruption of situation. for 15mins. minimized
skin surface Dress wound cross
( epidermis) with dry contaminatio
● Distruction of sterile n.
skin layers dressing , use
( dermis) pape tape ● To reduce
● Invasion of ● use pressure on
body approprate enhance
structures pading circulation to
● Physical devices ( eg. compromised
Assessment air water tissue.
reveals wound matterss ● to promotes
in the gluteal sheep skin) circulation
area. and reduces
● Encourage risk
early associated
ambulatory / with
immobilizatio immobility.
n
Assessment Diagnosis Planning Intervention Rationale Evaluation
Objective: Risk for infection After nursing care the •Stress the proper •a first line of After nursing care the
related from post patient will be able to hand washing defense against patient was able to identify
Inadequate primary operative wound identify interventions techniques. nosocomial infection interventions to prevent &
defense because of to prevent & reduce •monitor visitors •to prevent exposure reduce the risks for
broken skin the risks for infection. of client. infection.
•change dressing as •to promote fast
needed. healing
•cleanse incision site
daily with provide
iodine.
•use gloves when •to avoid transfer of
caring for the open microorganism
lesion.
•cover dressing with •to prevent
plastic when using contamination of
bed pan. wound
•maintain adequate •to avoid bladder
hydration distention.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Objective – Risk for imbalanced During the operation •asssess for clinical •signs of dehydration After the operation patient
Hypotension fluid volume related patient will be able to signs of dehydration signifies fluid loss was able to maintain stable
Increased heart rate to intra operative maintain stable fluid fluid volume.
Delayed capillary surgery. volume. •measure and record •to prepare for fluid
refill. intake and output management
(blood loss,urine).
•note presence of
bleeding
•calculate fluid •may be the
balance contributing factor
for fluid deficiency
•monitor blood
pressure response
•increased when
•administer IV fluids there is fluid deficit.
as prescribed
•to promote fluid
management